Your child is a real go-getter; maybe they’re a straight-A student or a star athlete. Lately, though, they have trouble breathing during very inopportune times, like before a test or a big track meet. You have seen their primary care doctor and you have seen a pulmonologist. Maybe they are put on an inhaler, but it doesn’t seem to be working like you hoped. So what’s going on?

Have you heard of vocal cord dysfunction? Well, there is a new name for it: exercise-induced laryngeal obstruction (EILO) and inducible laryngeal obstruction (ILO). That’s a mouthful.

Whenever there’s a “trigger” (i.e. exercise, stress, certain odors), the vocal cords narrow and it feels like you can’t get a good breath in no matter what you try to do. It isn’t life-threatening because your vocal cords are actually still open, but they aren’t open enough to fill your lungs. It’s scary. Your child is panicking and now you are, too.

What are the symptoms of EILO/ILO?

• Chest/throat tightness
• Difficulty inhaling
• Noisy breathing
• Shortness of breath

That sounds an awful lot like asthma, doesn’t it? You’re right; EILO/ILO and asthma sound very similar, but there are a few differences. Let’s compare the two:

You have ruled out asthma with your physicians and ruled in EILO/ILO. 

What do we know about EILO/ILO?

Onset can occur at any age, but most commonly, EILO and ILO are diagnosed in 12 to 18-year-olds.

It is most prevalent in our young athlete population and it can lead to anxiety about playing sports because of the fear of not being able to breathe. The same thing can happen around stressful situations like an upcoming AP history test or a choir performance.

Speech Therapy

What can be done to help these kids get back into their sports, extracurriculars, and high-demand classes? Speech therapy and/or physical therapy is the answer! And it’s all about breath.

With speech therapy, we look at how the child is breathing and teach them a variety of strategies to make their breathing more efficient.

We work on rescue breathing techniques that will blow the airway open during an active EILO/ILO episode as well as preventative breathing strategies that will keep the airway open during exercise or stressful activities. We also focus on diaphragmatic breathing or belly breathing, so the child can optimize the amount of air they are getting into their lungs at rest and during physical activity.

With physical therapy, we can look at the athlete’s movement patterns, posture, endurance, and strength that may be impacting their breathing. Oftentimes, stiffness or weakness through the trunk and core changes a person’s breathing pattern, causing them to have difficulty controlling their breath (especially during high-intensity activities).

This can lead to increased fatigue, tension around the neck and/or shoulders, and EILO symptoms. Another area of focus is cardiovascular endurance training to avoid the feeling of “hitting a wall” during exercise.

Through guided exercises, improvements can be achieved by reducing compensations or our body’s way of cheating through movements, training the proper muscle groups, and supporting proper muscle use and form during athletic movements.

What is the common goal? To give the child the skills they need to get back to the activities they love. If your child is experiencing any of these symptoms, reach out to their primary physician to discuss a potential referral to an ENT (otolaryngologist) or pulmonologist for further diagnostic testing.

Voice issues can be difficult to detect in anyone, especially children. You might sense that something sounds “off” with your child’s voice. Maybe their voice sounds rough, or raspy, or strained, or breathy.

First of all, what is a voice disorder?

According to the American Speech-Language-Hearing Association (ASHA), a voice disorder occurs when voice quality, pitch and loudness differ or are inappropriate for an individual’s age, gender, cultural background or geographic location.

Sometimes an older child can sense their voice is different and even though other people may not notice it, it’s impacting their self-esteem at school and with their friends. That can be considered a voice disorder, too.

It might be harder to tell in our little ones, so what should we look for?

Some signs and symptoms that you might be able to perceive in your own child include:

• rough or raspy vocal quality
• breathy vocal quality
• strained vocal quality (tense or harsh)
• abnormal pitch (too high, too low, breaks, decreased range)
• abnormal loudness/volume (too high, too low, decreased range, unsteady volume)
• running out of breath quickly when talking
• frequent coughing or throat clearing
• excessive throat tension/pain/tenderness

There are different causes for voice disorders ranging from structural to functional. What does that mean?

Voice disorders caused by an underlying structural issue can include paralyzed vocal cord(s), blisters or callouses on the cords or damage to the nerve in the brain that controls our voice.

Functional voice disorders are more common and are caused by abuse, misuse, and overuse of the vocal cords.

If your child screams a lot and they have a raspy voice, it could be from vocal cord abuse. That might sound a little confusing – my child is “abusing” his voice?

The tissue of the vocal cords is fragile, so if they come together too forcefully as they do with coughing, throat clearing, and screaming, they can become irritated. With repeated injury, it can cause callouses (nodules) to form on the vocal cords. This will prevent the vocal cords from closing all the way, allowing more air to come through which makes that raspy or breathy quality. In more severe cases, bleeding can occur on one of the vocal cords.

Other things that may possibly be hurting your child’s voice:

• Too much caffeine
• Not drinking enough water
•  Whispering
• Making funny noises
• Smoking or being around smoke
• Uncontrolled allergies or reflux

If your child isn’t using their voice properly, what can you do to help? 

The no. 1 recommendation is good vocal hygiene. Encourage your child to:

• Drink plenty of water
• Avoid clearing their throat and coughing. Instead: swallow hard or take small sips of water
• Talk in a normal voice; don’t whisper or yell
• Limit caffeine intake
•  Talk with their doctor about managing allergies and reflux
• Have quiet periods when they can rest their voice

What if those do not help? Talk to your doctor about speech therapy.

Speech Therapy

As speech therapists, we can help your child learn to use their voice in a healthier way. We teach that this starts at the power source: the breath.

Children can modify how they use their voice through a variety of strategies, such as breathing techniques, stretches to decrease tension in the neck and exercises for proper breath control that will create a strong, healthy voice.

If your child is experiencing any of these symptoms, reach out to their primary physician to discuss a potential referral to an ENT (otolaryngologist) for further diagnostic testing.

We only have one voice and we want to protect it.

All children learn to babble and talk at different times. Before you know it, they can read their favorite book or tell you what they want for their birthday. But, when they can't tell you what they want to eat for breakfast or the daycare teacher can't understand what they say, parents need somewhere to turn.

At Cook Children's Rehabilitation Services, our speech language pathologists (SLPs) are highly skilled and experienced in children's communication development. They work with parents to help empower their children to achieve their goals.

We have about 40 SLPs who serve our patients in our medical center and outpatient clinics. They have expertise in:

• Feeding/dysphagia
• Speech/language skills
• Augmentative and alternative communication
• Hearing loss
• Autism
• Traumatic brain injury and so much more!

As we celebrate Better Speech and Hearing Month this May, Jonathan Suarez, Rehabilitation Services clinic lead, and Suzanne Bonifert, Rehabilitation Services manager, provide answers to commonly asked questions about speech and hearing.

What can I do to get my child to speak more?

Model words for your child, even if he/she doesn’t repeat them. For example, if he/she vocalizes and points to juice, you can say, “juice” or “you want juice.” That way the child is hearing the words even though he/she cannot say them yet.

It’s also good to use comments (i.e. “You want juice.”), rather than questions (i.e. “What do you want?”). Doing so can be less stressful for kids, especially those having some challenges learning to talk.

We also recommend talking to your pediatrician about a referral to see a SLP for an evaluation. The SLP can help you identify your child’s strengths and challenges and may recommend therapy to help give your child a boost!

Is it OK to speak more than one language to my child throughout the day?

Yes, yes and yes! Every child is different and the amount of time they spend using each language can vary, depending on exposure in school, at home or during extracurricular activities.

Sometimes a child may understand multiple languages but will only use one. Keep practicing each language!

Some children may “code switch,” or use both languages when they speak. This is not a disorder. The child is learning how to use the rules of both languages.

How do I know when to be concerned about my child’s communication or when to see a speech therapist?

By the time your child is 12 months old, he/she should be able to speak two to three words. By the time he/she is 2 years old, he/she should be able to speak at least 200 words. By age 3, he/she should be able to speak 900 words.

Trust your gut. If you feel there is a concern, you can ask your pediatrician for a speech therapy referral and have your child evaluated.

Once the evaluation is complete, an SLP can provide information to help with your child’s communication.

Here are links to two helpful speech and language milestone charts:

• Speech and Language Milestone Chart, LD Online
• Speech and Language Developmental Milestones, National Institute on Deafness and Other Communication Disorders

Is there something I could have done as a parent to prevent my child’s speech delay?

No. We often hear parents say, “We never had to worry about my older children talking.” But there is nothing you could have done to prevent your child’s speech delay. In most cases, there are steps you can take now to help your child’s language skills grow.

Since your child has a language delay, we need to be intentional in the language we are using with them.

How long will my child need to be in speech therapy to gain the skills they need to communicate?

Progress can vary from child to child. Our goal is to improve the child’s language while also teaching the parent or caregiver some interaction and language strategies to elicit communication.

What can a speech therapist do with a toddler who cannot sit still?

We can teach language in a variety of ways! Activities involving movement are great for keeping children interested. Sometimes, children are having so much fun that they do not realize they are actually doing a language activity!

Instead of sitting at a table for activities, you could:

• Stand up and sing songs using motions and actions
• Play hide-and-seek
• Play chase while running, jumping or skipping
• Read a book while acting each part out

To learn more about the Cook Children’s speech therapy program, please visit our website. 

I have a few tricks up my sleeve: fun toys, silly pictures, asking them about something they brought in or something they are wearing. When I’m asked to evaluate a child who isn’t talking, I begin with some easy tasks like pointing to things or naming familiar items. Most kids begin to warm up in a short amount of time and I frequently have to steer them back toward our speech activities because there is so much more they want to talk about.

But sometimes a child won’t talk to me. Week after week, they won’t talk to me.

Parents tell me that he talks a lot at home, A LOT, but rarely to other people or away from home. This is more than being shy. When the parent describes what the child says at home, I learn that they use a variety of words and usually talks in full sentences. Sometimes, I’m able to determine that the child doesn’t even have a speech problem. They may have an anxiety disorder called Selective Mutism.

Selective Mutism is a childhood social communication anxiety disorder. It occurs when children do not speak for at least 1 month in certain social settings, but are able to speak in other settings. (Important note: this does not include kids that refuse to speak during the first month of school or children learning a new language.) The inability to speak is not related to a speech delay or disorder and is not the result of other medical or psychological problems that interfere with speech.

When it comes to talking or engaging with people, some kids experience an extreme level of fear and anxiety causing them to be silent, or mute. Maybe they are afraid to engage with other people or afraid they will embarrass themselves when they speak. In the moment, no amount of reassurance or pressure will help them bring words out. They are frozen.

Some studies estimate that this happens to 1 in 1,000 children*. However, several researchers have stated they believe this is largely underestimated. Selective Mutism is slightly more common in girls than boys. Most kids are diagnosed around the age of 5, but parents report difficulty starting years earlier. Selective Mutism may last for months or years. It may even extend into adulthood if left untreated.

What should parents do?

Never try to force or bribe a child to speak.

Talk to your doctor or a psychologist. They will likely gather a team to help diagnose your child’s difficulty and develop a plan of care:

• Are there hearing problems?
• Does she have difficulty speaking or being understood?
• Has there been a recent traumatic event?
• Does she express fear about talking or other things?

Frequently there are other underlying issues that have led to the anxiety disorder.

A psychologist or counselor can help your child understand their fears and work through them using play therapy, family counseling and behavioral or cognitive strategies.

Many times a speech language pathologist is called in to help. I know this seems unusual as we have just said there is not a speech problem, but an anxiety disorder. However, speech language pathologists  are able to set up activities in a nonstressful manner with low expectations for talking.

Let’s start with playing with a train set. The therapist helps the child build the train track and continues to make comments about the activity, train sounds and try to engage in taking turns with the child creating a fun shared activity.

The next level may include asking the child to point to a picture of the train car they want to put on the track first. Recently, a child I was seeing began saying the color as they were touching the picture. I smiled and continued playing, not making a big deal about them speaking.

Slowly, week after week, the therapist helps the child build success and confidence.

We set up activities that include more people and work with parents to design practice activities they can do between therapy visits. As we provide more challenging activities, we always have a backup plan ready if the child begins to feel unsure.

With older children, once we build trust, we can help them identify challenges in speaking or socializing. We can build on skills they already have and gain confidence in communicating with others. We will also help them problem solve specific situations that cause stress.

If you suspect your child has difficulty speaking, whether it be due to anxiety or other speech skills, please talk to your pediatrician to seek help.

* Estimate from Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

Wheezing, coughing and the struggle to catch a single breath.

Sounds like asthma, right?

But there may be another cause for respiratory distress in your child: vocal cord dysfunction.

Asthma and vocal cord dysfunction (VCD) seemingly show the same symptoms, especially in adolescents. But what’s the difference between them?

Cook Children’s Emergency Department sees an average of 13,000 children each year exhibiting wheezing and difficulty breathing. The similarity of symptoms between asthma and vocal cord dysfunction may be difficult to differentiate to the eye so it’s important to note the small distinctions.

“Asthma and VCD are quite different even though some of the symptoms can overlap,” Corwin Warmink, M.D., medical director of Emergency Services at Cook Children’s said. “VCD causes difficulty breathing in compared to asthma, which makes it more difficult to breathe out. They also sound different when using a stethoscope to examine a patient.”

Unlike vocal cord dysfunction, asthma is an immune response when the body is exposed to various “triggers,” such as air pollutants, physical activity and airborne particles like pollen and pet dander. When triggered, the bronchial muscles in the airways constrict and the sudden obstruction causes the reaction of an asthma attack.

You may be experiencing an asthma attack if your symptoms include:

• Tightness in the chest

• Difficulty breathing

• Shortness of breath

• Coughing and wheezing

• Excess mucus

Vocal cord dysfunction is the abnormal closing-together of the vocal cords, resulting in the loss of airflow. Unlike asthma, VCD does not involve an immune response or a reaction from the airways. Vocal cord dysfunction makes it more difficult to breathe in than breathe out when symptoms occur.

Children who are active, vocal and use their vocal cords more than usual may have higher tendencies to experience VCD.

“We see VCD most common in female teenage athletes although it does occur in males,” Karen Schultz, M.D., pulmonologist at Cook Children’s said. “Type “A” personalities are at higher risk.”

You may be experiencing vocal cord dysfunction if your symptoms include:

• Tightness in the throat

• Difficulty breathing

• Coughing and wheezing

• Hoarse voice

Asthma and VCD are regularly confused as the symptoms and triggers are similar. Many patients with VCD are originally treated for asthma.

“Patients are diagnosed by history, exam and lung function testing,” Dr. Schultz said. “Lung function testing can be completely normal in both conditions when no symptoms are present. Frequently history alone can differentiate the two. Occasionally lung function testing after exercise can be diagnostic or laryngoscopy after exercise”

Signs you may be experiencing VCD instead of asthma:

• It is more difficult to breathe in than it is to breathe out

• Asthma medications and inhalers do not ease symptoms

The diagnoses for VCD and asthma are different. Asthma requires pulmonary function tests, such as a peak flow and a spirometry test. While a diagnosis for vocal cord dysfunction typically entails results from other pulmonary function tests, such as a laryngoscopy or a spirometry test.

Many children who are diagnosed with vocal cord dysfunction are referred to see a speech pathologist who can assess the degree of dysfunction, and begin a plan of action with different types of breathing and stretching exercises for the vocal cords.

“There are a number of ways we treat different diagnoses, but we will usually start with breathing exercises to make sure air flow is unhindered and the vocal cords can be well supported,” Melanie Van Noy, speech pathologist at Cook Children’s said. “Then we may do simple exercises to lengthen and stretch the vocal cords or exercises to reduce pressure. It depends on the diagnosis and the dysfunction.”

While VCD does not have specific medications to ease symptoms, speech therapy is tailored to allow children and their families learn triggers and how to cope when an attack does occur.

“For kiddos, a large part of our job is helping our young patients to become more aware of their vocal habits and educating not only them but their parents and siblings on how they can help change those habits, Van Noy said. “We also have some sophisticated software programs that help give our kiddos the feedback they need so they can not only hear the difference, but see the difference and the changes they are making as well.”

Speech therapy typically teaches and treats children for three to five sessions. If the child is still showing symptoms, a team of Cook Children’s doctors will begin to assess all the different aspects to their case.

“Our ENTs and pulmonologists work closely together to ensure that if our treatment plateaus or the patient is still showing symptoms despite treatment, we can collaborate on what to do next,” Van Noy said. “That may look like a discussion with the physician regarding compliance and progress of treatment, what other medical intervention strategies are available or maybe just another episode of care, which is what we refer to as our plans of care.”

His mom, Crystal, will be the first to tell you her little boy is just "a really cool kid."

Have you ever gotten to a point in doing something so much that you feel like you just need to take a break?

No … I’m not talking about marriage. I’m talking more like working out. You know what I mean. You get to the point where you’re doing like 2 or 3 hundred pushups in a row. Who am I kidding? I’ve never done that many pushups. But I have tried having a trainer before. I remember getting to a point in the training where I felt like I could basically take over. As I did the exercises, I knew when my form was off and I knew what exercises I needed to improve on.

Speech therapy can be the same way. So many times, we want therapy to continue year after year after year. I get it. It’s hard to let go of something you know is helping your child. But breaks are sometimes not only needed, but beneficial.

Often, when working out you come to some sort of plateau. You feel like no matter what you do, you aren’t improving. Well, that’s when you can go back to the trainer, who will help you make adjustments and keep the improvement going. Speech language pathologists (SLP) are really knowledgeable and can help adjust your child’s plan of care so your child continues toward attaining his or her true potential.

Let’s first address the purpose of therapy. Your speech language pathologist’s goals should be:

1.Work with you to figure out the needs of your child and how their speech and language difficulties are affecting their day to day life and learning.

2.Come up with a treatment plan that allows for your child to improve in the areas you and the SLP feel are important.

3.Teach you strategies you can use to work on the things your child has trouble with as well as discuss activities that can be done outside of therapy.

4.Teach you to be your child’s speech therapist at home!!

As a clinician, I feel No. 4 is most important. Most kids get therapy maybe 1-2 times a week for about 30-60 minutes. Most parents feel that isn’t enough.

I AGREE!!!

Just imagine if you could learn everything the therapist was teaching and the strategies to teach the concepts. Your child would be getting therapy basically at all waking hours. All of a sudden your interactions change. For example, you know that when your child has difficulty understanding a direction, you can assist them by using the “breakdown” strategy.

This is where you maybe break the direction up into pieces. For instance “Dominic, go to your room and get the ball.”

Well little Dominic may just look at you with a confused face. Kind of like the face my wife says I have when she asks me to do something. But that’s neither here nor there. By “breaking down” the direction, you may first say “Dominic, go to your room.” Then, when that is complete you say “Get the ball.” This allows him to fully understand the direction. Similarly, you may use a strategy that would make it easier to produce a sound, such as providing a tactile or visual cue.

Let’s say little Mia has difficulty producing the “B” sound. We may point to our lips to get her to realize that we need our lips to make lip sounds. Now that is awesome. When children apply what they have learned in therapy, it is wonderful because we want children to improve; BUT when parents apply what they have learned, it is magical. Questions to ask your therapist could include:

1.What are the goals for my child?

2.What strategies are you using to assist my child and teach them the concept? Can you teach them to me and help me do them correctly?

3.What can I do at home to help with generalization of the skill?

Every child is different so each plan of care may differ in how long therapy lasts. At some point though, through ongoing discussions with the clinician there should be an ending point. You get to now apply what you and your child have learned in therapy.

Keep in mind that this isn’t the end-all-be-all. In most cases, I recommend a re-evaluation in 6 months to ensure that there is continued improvement or even to adjust the plan of care. As a therapist, I understand there still may be concerns. I want, however, my parents to feel empowered by the knowledge they now possess. My goal is that the parent leaves my therapy session understanding our objectives and strategies.

Bob Keeshan made a good point when he said “Parents are the ultimate role models for children. Every word, movement and action has an effect. No other person or outside force has a greater influence on a child than the parent.”

Aye, aye captain.

As a child, Rousey was diagnosed with Childhood Apraxia of Speech (CAS), a motor speech disorder. In recent interviews Rousey reports struggling with feeling of insecurity and inferiority following her diagnosis of CAS. During Rousey’s early years, there was question as to whether she would ever be able to use conversational speech. But with perseverance, intervention, and encouragement from her speech therapist and family, Rousey is now a well-spoken adult with a message to children with CAS: anything can be overcome with hard work no matter how insurmountable the odds seem.

Children with CAS have problems saying sounds, syllables and words in the absence of muscle weakness or paralysis. Basically, the brain has trouble telling the body parts necessary for speech how to move in order to form speech. Children diagnosed with CAS don’t follow normal speech sound development and won’t “catch up” to their peers without intervention.

So what causes CAS? Unfortunately, in most cases we don’t know. CAS is a motor speech disorder, meaning something is interfering with the brain’s ability to tell the mouth muscles how to make the right sounds. Possible causes include genetic syndromes, stroke, or brain injuries or abnormalities. While there is no cure, we know miraculous progress can be made given skilled intervention.

Not all children diagnosed with CAS will present the same way, but diagnostic signs or symptoms do exist. A child with CAS:

• May not babble or coo very consistently during infancy.
• Uses very few consonant and vowel sounds and has a hard time combining sounds to form words.
• Understands much more than he can tell us.
• May say a word clearly once or twice, but then doesn’t say it again.
• Struggles to imitate speech models. You may even be able to see him groping or struggling to coordinate his mouth when trying to talk.
• Has more difficulty saying long phrases and sentences than short ones.
• May have choppy speech with long pauses between sounds.
• Can be very difficult to understand, especially if you aren’t familiar with his speech patterns
• May have some difficulty eating

If this sounds like your child, an evaluation by a speech-language pathologist is imperative. A skilled therapist will help determine the best course of intervention. All children are so very unique, and therefore, treatment plans will be custom created based on several factors, including age, severity, and of course, your family’s schedule. However, research shows children diagnosed with CAS have a greater likelihood of success if they:

• Receive frequent and intensive intervention (think 2-4 sessions per week in a perfect world). It’s important to remember the age and tolerance of your little guy when scheduling therapy. Four sessions a week may be too much for him.
• Have the opportunity to work one on one with their therapist.
• Are exposed to a “multi-modality” approach to intervention. This is just a fancy way to say using many different cues and strategies to help them create the sounds, including touch (helping him move his lips to say “pa”), visual (looking in a mirror), and proprioceptive (pairing movement with sounds) cues. These kiddos need to learn and remember HOW to move their speech muscles so your therapist may encourage them to repeat a word or syllable many times.
• Practice, practice, practice at home! Even an intensive therapy program will give your child 3-5 hours a week AT MOST with his speech therapist, meaning he has 163-165 hours per week OUT of therapy room. Use those hours wisely and carve out time to practice everyday to see progress!

Resources for families:

Apraxia-kids.org

References:

ASHA.org - Childhood apraxia

*Photo from Ronda Rousey's Facebook page.

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.